Clark University
950 Main Street • Worcester, MA 01610
Tel: 508-793-7711 •

Fall 2009 Online Application

1-TO-1 SWIM LESSON PROGRAM

THIS FORM IS FOR NEW FAMILIES ONLY.

You will be slotted as openings develop based on your day/time preferences. You will be notified if there is an opening. If there is not an opening you will be placed on the waiting list and notified in the order this form was received as openings develop for the next session.

Please Note:

Please rank lesson times. Details and confirmation will be sent via email.

Child #1 First Name Last Name Sex Birthdate Month Day Year
Child #2 First Name Last Name Sex Birthdate Month Day Year
Child #3 First Name Last Name Sex Birthdate Month Day Year
Please Rank Scheduling Preferences 1st Choice: 2nd Choice: 3rd Choice: 4th Choice: 5th Choice:
Parent/Guardian Information
Mother First Name Mother Last Name	Father First Name Father Last Name
Email	Alternate Email (optional)
Home Phone	Cell Phone
Home Address
Street	City/Town
State Zip
Clark Affiliation?
Employee Name (if not parent) : Relation:
Alumni Class of: Relation:

Comments, Concerns, Questions By submitting this form I acknowledge that I have read and understand the procedures and guidelines for the 2007 One-To-One Swim Lessons Program.